O&T: Spine Flashcards
Spine function
- Protect spinal cord
- Transfer loads (through disc, facet joints)
- Trunk support (through muscle attachments)
- Motion (flexion / extension, lateral flexion, rotation)
- Chest wall attachment (e.g. ribs, musculature to maintain respiratory function)
Neck / Low back pain
- Low back pain most disabling
- Prevalence up to 83% in one’s lifetime
- Musculoskeletal issues are highest burden in terms of global disease
- 20% patients seen in GP complains of back / neck problems
Back pain:
- Mostly benign
—> 60% subside in 1 week
—> 90% in 6 weeks
—> 95% in 12 weeks
- Variable severity
Approach to Back pain
- Identify cause
- Rule out sinister condition
- Localise source of pain by P/E
- Guide appropriate investigations + treatment
***DDx of Back pain
Mechanical pain (97%):
1. Back sprain (>70%)
2. Lumbar disc degeneration
3. Lumbar disc herniation
4. Spondylolisthesis
5. Fracture
- Vertebral body
- Spondylolysis
Non-mechanical (3%):
1. Neoplasia
2. Inflammatory arthritis (AS / Spondyloarthropathy)
3. Infection
4. Non-spinal diseases
- Pelvic inflammatory disease
- Endometriosis
- Nephrolithiasis, Pyelonephritis
- Aortic aneurysm
Common causes:
1. Myofascial sprain
- heals quick ~4 weeks
- by strenuous activity
- avoid provocative activity
2. Facet joint degeneration (back pain + referred pain)
3. Disc degeneration
- outer annulus of disc
- facet joint capsule
- chemical and mechanical irritation of nerve root
***History taking of Back pain
- Onset
- Acute (<1 month): fracture, infection
- Subacute (1-2 months): tumour, infection (e.g. TB)
- Chronic (>3-6 months): degenerative, claudication - Radiation / Leg pain
- Lower back to paraspinal musculature, SI joint, buttocks, posterior thigh
- Extension below knee —> indicate ***nerve root is involved —> follows dermatome - Mechanical vs Inflammatory
- Mechanical: pain when moving
- Inflammatory: pain at rest, improve with moving - Aggravating factors
- Heavy exertion, repetitively bending, twisting, heavy lifting
- Pain on lumbar flexion (disc herniation)
- Pain on extension and rotation / lateral flexion (facet joint)
- Pain on walking / leg symptoms (**spinal claudication / **spinal stenosis) - Night pain (sinister)
- Neurological deficit
- **Claudication distance (indicate severity)
- **Sciatica (Radicular pain)
- Numbness
- Weakness
- Unsteady gait (in severe motor deficit / cord compression resulting in proprioceptive loss)
- Sphincter control - Constitutional symptoms (fever, weight loss, appetite loss)
- Previous treatment (e.g. Failed back syndrome: chronic pain following back surgeries)
Other history:
9. Age (inflammatory, sarcopenia)
10. Smoking, DM, Immunosuppression, Drug abuse
11. Malignancy (past / family history)
12. Degree of limitation of pain (work, sleep)
13. Psychological state / emotional distress
**Red flag signs:
Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, **Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain
Claudication vs Sciatica vs Radiculopathy
Claudication / Neurogenic claudication:
- Usually refer to **Spinal stenosis
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- **Upright standing / ***Walk certain distance —> develop burning / numbness / pain in lower limbs —> usually cannot tell exact dermatomal location (usually vague sensation)
(Vascular claudication:
- Calf spasms (vs Burning / Numbness pain)
- Relieved by resting (vs Flexion in neurogenic claudication)
- Atrophic changes in toes, loss of hair
- Loss of pulses)
Sciatica:
- Pain radiating down the leg
- Radicular pain in certain distribution (e.g. calf, foot dorsum)
Radiculopathy:
- Pain related to single nerve root —> single dermatome
- Pain on walking / certain positions (e.g. sitting, flexion)
- Indicate ***disc pathology causing spinal stenosis
NB:
1. Can have both sciatica and claudication at the same time in nerve root compression
2. There is NO lumbar myelopathy (∵ cauda equina —> all are nerve roots)
***Red flag signs
Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, ***Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain
***P/E of Spine
Look:
1. Deformity
- Standing posture
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis - ***Listing
- Herniation lateral to nerve root (compressing on “shoulder” of nerve root) —> lean to contralateral side
- Herniation medial to nerve root (compressing on “axilla” of nerve root) —> lean to ipsilateral side - Muscle atrophy (indicate chronicity ∵ denervation of muscle)
- ***Modified Schober test
- Assessment of spine movement (Flexibility)
- Disc herniation will cause limitation in flexion - ***Gait (may indicate cord compression)
Feel:
1. Tenderness
- Muscle
- Spinous process
- SI joint
- Hip
- Tone (UMN vs LMN lesion)
Move:
1. ROM
- Forward flexion / extension
- Lateral flexion
- Neurology
- Motor
- Sensory
- Reflex
Special test:
1. **Straight leg raise test / Lasegue test / Bowstring test
- Patient lying supine —> Passive elevate leg in a straight leg —> stretch **sciatic nerve (L4-S3) —> pain (Normal: 70o) (positive: radicular dermatomal pain, same type of pain as patient’s experience, <70o)
—> **Cross straight leg raise test —> lift contralateral normal leg —> pain in problem side (∵ pulling of involved nerve root against axillary / posteromedial compression, negative in shoulder / far lateral compression)
—> **Lasegue test (confirmation test) —> lower leg a bit until no pain —> passive dorsiflex ankle to reproduce pain
—> ***Bowstring test —> gradually flex knee until no pain —> compress on popliteal fossa to reproduce pain (Alternative: 90o flex hip, 90o flex knee, extend knee until pain, drop a bit then compress on popliteal fossa)
- Femoral nerve stretch test
- Prone position —> Hip extension —> stretch ***femoral nerve (L2-L4) - Circulation (Vascular problems can always mimic spinal problems)
***Investigations of Back pain
Infection:
1. WBC
2. ESR (high blood fibrinogen causes RBC to stick to each other) (chronic cause)
3. CRP (6-8 hours after onset of infection) (acute cause)
Burn turnover markers (Malignancy):
4. ALP
5. Globulin
6. CaPO4
Malignancy:
7. Serum protein electrophoresis (Multiple myeloma)
8. Tumour markers (e.g. CEA, CA19.9, PSA)
Imaging
- Treat symptoms not images
- Imaging should be confirmatory tests
- Must explain to patients the reason for MRI
- X-ray
- correlation with symptoms
- positive history
- malignancy and infection
- false assurance? (False negative ∵ not completely sensitive to diseases esp. in early stages) - CT
- assess fracture configuration - CT myelogram
- MRI
- assess disc, soft tissue, canal pathologies
- nerve compression
- sinister pathologies (e.g. tumours, infection)
- confirmation of lesions
***Interpret X-ray of Spine
- Alignment
AP view:
- Spinous process (rotation / malalignment, scoliosis)
- Lateral edge of Vertebral body (laterolisthesis)
Lateral view:
- Anterior longitudinal ligament (spondylolisthesis)
- Posterior longitudinal ligament (retrolisthesis)
- Spinal laminar line
- Spinous process
- Normal curvature of spine (Lordosis, Kyphosis)
- Bone
- Size + Height
- Vertebral body (↑ size from cranial to caudal in lumbar spine)
- ***Pedicles (erosions may indicate metastasis)
- Transverse process (attachment of psoas, if psoas pull too hard —> transverse process fracture)
- Spinous process - Collapse
- Disc space
- Smooth
- Largest on L4/5 —> L5/S1 —> L3/4 - End plates
- Smooth - Foramen (Lateral view)
- Girdle (SI joint)
- Erosion / Fusion
- Sclerosis line - Height
- Iliopsoas shadow
- Tumour / Abscess / Haematoma can disrupt outline - Interarticularis (below pedicle of each level)
- Discogenic back pain
- Back pain caused by disc herniation
- Worse in forward ***flexion postures
—> Sitting
—> Bend forward to tie shoes
Pathophysiology of Disc herniation:
Rim lesion
—> Annulus tear
—> Lose ability to absorb shock
—> Shortened disc space
—> Herniated nucleus pulposus
—> Herniated content go into spinal canal
—> Nerve compression + Leg symptoms
Pain caused by:
1. **Biomechanical problems (Modic changes —> instability of spine)
2. **Cytokine release (Inflammatory)
3. ***Ingrowth of nerve and vasculature to the disc after annular tear
Features on X-ray:
- Disc space narrowing
Features on MRI:
- **High intensity zone in disc (inflammatory lesions at anterior / posterior aspect of annulus —> indicate **annulus fissure)
- ***Darker disc (degenerated disc)
- Posterior annulus fissure
- Compression of nerve root
Treatment:
Conservative:
1. Avoid flexion posture
2. Injection of LA in area of annulus tear to reduce pain —> but controversial since puncture can lead to more damage / degeneration of annulus
Surgery:
1. Decompression (RFA to cut away protruded segment of disc —> but do not treat pathology —> if heavy loading again disc can still progress to prolapse)
2. Spinal fusion
- Facet joints
- 2 Facet joints per spinal segment
- Sliding joints with ***lots of nerve fibres (dorsal rami of spinal nerve)
Facet joint arthrosis:
- Pain on **extension
- **Lateral extension for side of facet joint arthrosis
- Indicates overload of facet joints —> part of **Disc degenerative cascade (Disease origin at the **disc —> degeneration of disc —> overload facet joint —> ***spondylolisthesis)
- Bright signal in T2 weighted MRI due to edema
Hypertrophy of facet joint:
- ***Narrowing of intervertebral foramen
Treatment:
1. Back muscle strengthening
2. Facet joint injections of LA / Steroids
- Spondylolysis
***Pars interarticularis defect / fracture —> discontinuation of adjacent vertebra
Clinical features:
1. LBP with insidious onset (can be acute if acute hyperextension (e.g. diving, weight lifting, gymnastic))
2. Radicular symptoms only with **Spondylolisthesis (only in severe case will Spondylolysis develop into Spondylolisthesis) (Pars defect alone does not compress nerve root)
3. **Hamstring spasm (flexed hips + knees)
4. Shortened stride length
5. ***Flattened lordosis
Investigations:
1. X-ray
- Oblique view for “Scotty dog” appearance: break in pars —> break in dog’s neck
2. Single photon emission CT (SPECT): increased radionuclide uptake as stress reaction
3. CT
4. MRI
End-stage degeneration:
- **Spondylolisthesis
—> Radiological instability
—> **Spinal stenosis by kinking centrally / compression by superior articular process impingement at foramen / excessive movement can also cause osteophytes, ligamentum flavum hypertrophy
Treatment:
1. Rehabilitation
- core strengthening to prevent progression
- Protect in acute cases
- bracing
- activity avoidance
- resume all activities once symptoms resolve - Surgery
- rarely needed
- stabilise spine
- high grade slips in adolescents
- non-union fracture
- neurological symptoms
Spondylolisthesis
Many types / causes:
1. Degenerative of facet joints (elderly)
2. Spondylolysis (younger)
Etc.
Causes: (SpC Revision)
1. Dysplastic (Congenital malformations)
2. Isthmic (i.e. Pars fracture) (Stress fracture in gymnast who arches back a lot, Elongation of pars due to various reasons) (common, can slip >25%)
3. Degenerative (Loss of disc height: usually only minor slip <25%)
4. Traumatic
5. Pathologic (Pagets, Metastatic disease)
6. Iatrogenic (After surgical excision)
- Spinal stenosis
Spinal canal narrowing with possible ***nerve root compression
Causes:
1. IV disc herniation (but with positive SLR test (self notes))
2. Osteophytes
3. Facet joint hypertrophy
4. Ligamentum flavum hypertrophy
Clinical features:
1. **Neurogenic claudication
- **Walking increases severity of burning / aching pain, numbness (dermatomal), paresthesia, subjective / objective weakness
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- Burning / Numbness in lower limbs
2. Leg / Back pain
3. **Motor deficit
4. **Sensory disturbance
5. Reflex alterations
6. ***SLR test negative (SpC Revision)
7. Lots of symptoms but no signs on examination (e.g. -ve SLR test) (SpC Revision)
Cauda equina syndrome:
- Severe stenosis
- **Acute LBP
- **Sciatica
- **Saddle paresthesia
- LL weakness
- Gait dysfunction
- **Sphincter incontinence
- Bimodal distribution:
—> Young: Large central disc herniation (after acute trauma)
—> Elderly: Chronic deterioration of spinal stenosis
Treatment:
1. Surgery
- Dural sac + Nerve root decompression —> target cause of stenosis
Spinal canal anatomy
Part:
1. Central
- Lateral recess
- bound by medial border of facet joint + intervertebral foramen laterally
- nerve root of **next lower level (aka **traversing nerve root) start to exit
- compression of nerve roots a level below (L3/4 disc compress L4 nerve root) - Foraminal
- nerve root of ***same level exited
- Sacroiliac joint pain
- Mimic back pain (esp. buttock pain)
- Usually diagnosis of ***exclusion
Treatment:
1. Conservative (Majority)
- Physiotherapy
- Analgesic
- Injection
- Surgery (Very rare)
- Fusion
- Ankylosing spondylitis / Spondyloathropathy
- Axial vs Peripheral
- ***Asymmetrical peripheral arthritis
- Affects women as well as men (M>F)
- Familial aggregation
- Association with ***HLA-B27 (not diagnostic)
- Rheumatoid factor ***negative (Seronegative)
Early diagnosis important:
1. **Clinical
2. Radiological (MRI?)
- SI joint eroded —> sclerotic —> fusion
- **Syndesmophytes + ossification of anterior / posterior longitudinal ligaments (caudal to cranial) —> connecting adjacent vertebrae together —> very stiff spine (“Bamboo spine”)
- ***Enthesitis
3. Blood tests
Inflammatory back pain:
- Onset of back pain before 40 yo
- Insidious onset
- Persistent for >=3 months
- Morning stiffness
- Improve with exercise
P/E:
1. **Schober test
- midpoint of PSIS + 10cm above
- bend forward
- normal >5cm increase
2. **Occiput-to-wall test
3. ***Chest expansion
- Global imbalance
Degenerative scoliosis / Adult deformity
Clinical features:
1. Coronal
- Truncal translation, shoulder / pelvis asymmetry
- Rib on pelvis impingement
- Sagittal
- Unable to stand upright, forward stooping posture
- Muscular fatigue and discomfort, decompensation with walking
- Hip extensor weakness (∵ chronic use to maintain upright posture) - Postural imbalance
- Cone of economy
—> body can remain balanced in only a narrow range (esp. narrow in spine deformity)
—> deviation from stable zone
—> increased muscle / energy use
—> mechanical disadvantage
Treatment:
1. Surgery
- Osteoporotic vertebral fracture with non-union
History:
- May not have injury —> ∵ Fragility fracture in osteoporosis
- An episode of sudden increase in back pain
- Gradual decreased mobility
Clinical features:
1. No pain —> Increasing pain on posture change —> Pain decrease after settling
2. Usually fracture can heal —> but with non-union —> big gap —> instability —> **neurological symptoms
3. Neurological symptoms
4. **Kummel’s disease
- 6-8 weeks after vertebral collapse —> osteonecrosis of remaining posterior body (∵ lack of blood supply) —> further collapse due to weakened bone —> sudden deterioration of neurology (∵ instability causing nerve compression)
X-ray:
1. **Decreased vertebral height
2. **Intra-vertebral lucency
3. Provocative radiograph: Opening up on extension (Vacuum sign) —> instability
4. Provocative test: Marked pain
MRI:
1. Fluid signal inside vertebra —> ∵ accumulation of fluid in non-union space
Treatment:
1. Conservative
- If only collapse
- Symptomatic relief —> Fracture usually heals
- Surgery
- Neurology —> Decompression
- Instability —> Stabilise (posterior fixation feasible) —> Cement injection
- Deformity (usually kyphotic) —> Correction (to avoid imbalance)
Difficult in osteoporosis:
1. Multiple fractures
2. Poor recipient bone for fusion
3. High non-union rate
4. Stress riser after stabilisation (adjacent level fractures + collapse ∵ implant are rigid)
5. Elderly with co-morbidities
- Metastatic spinal tumour
Clinical features:
1. Rest / Constant pain
2. Constitutional symptoms
3. History of malignancy
X-ray:
- Destruction not evident until after 30-50% of cancellous bone destroyed
- **Winking owl sign (classical finding on AP, erosion of pedicles —> **asymmetrical collapse)
Treatment:
1. Understand the pathology
- Tumour type
- Prognosis
- Organ involvement
- **Adjuvant options available to patient? —> if yes than separation surgery may be needed to facilitate adjuvant therapy
- **Potential targeted therapies (histological diagnosis): EGFR, TFF-1
- Surgery
- Palliative decompression
- Tumour debulking
- Separation surgery (separate tumour from spinal cord to allow stereotactic body RT —> avoid radiation neuritis)
- En bloc excision (in single level involvement with high life expectancy)
- Infection
Indications for surgery:
1. **Neurological compromise
2. Abscess
3. Biopsy for uncertain diagnosis
4. Disease progression, uncontrolled symptom
5. Late **deformity and ***instability due to bone erosion (relative)
Aims:
1. **Pathology for specimen
2. **Abscess drainage
3. ***Debridement of dead tissue
4. Stabilisation
TB vs Pyogenic infections:
- More indolent, slow growing
- Less prominent clinical symptoms initially
- More bone loss
- ***Subligamentous spread (e.g. spread along underneath posterior longitudinal ligament to other levels) (Pyogenic infection: can break through ligament —> cause abscess)
(From JC Surgery: Spinal infections
Causative agents (most common —> least common):
1. Bacterial
2. Mycobacterial
3. Fungal
4. Parasitic
Pathologies:
1. **Spondylodiscitis (Most common, infection of **Vertebral body + Disc space)
2. **Spondylitis (TB)
3. **Paraspinal abscess (e.g. Psoas abscess, Abscesses at paraspinal muscles)
4. ***Epidural abscess (cause neurological deficits)
5. Discitis (Children)
6. Facet joint septic arthritis)
DDx of Neck pain
- Axial neck pain (midline, focal tenderness in C-spine) vs Radicular neck pain (radiation, nerve root involvement)
- Radiation (dermatomal)
—> Occiput (may cause dizziness)
—> Periscapular
—> Upper limb
Common causes:
Mechanical:
1. Degenerative disc / facet
2. Nerve compression
3. Cervical instability (inflammatory / congenital)
4. Soft tissue injury
Non-mechanical:
1. Inflammatory arthritis
2. Neoplastic
***P/E of Cervical spine
Look:
1. Head + Neck posture (e.g. torticollis, protracted / retracted head posture)
2. Muscle wasting
- Shoulder (deltoid, rhomboid, trapezius)
- Back
- Scapular
3. C-spine (Front + Lateral)
- Front: Lateral deviation
- Lateral: Lordosis
Feel:
1. ***Tenderness along C-spine
- Spinous process
- Paraspinal muscles
- Compression of hyoid bone (C3 vertebra), thyroid cartilage (C4/5 vertebra), cricoid ring (C6 vertebra), carotid tubercle of C6 vertebra —> may elicit tenderness in cervical spine
2. Stepping
3. Shoulder problem? (Neck pain may mimic shoulder problem)
Move:
1. ROM
- Flexion / Extension
- Lateral flexion
- Rotation
2. Shoulder examination
Neurological exam:
1. **Motor
- Myotomes
- Muscle power (apart from active movement against resistance / gravity, MUST also have **full ROM)
- ***Sensory
- Dermatomes
- ASIA Sensory 3 point scale (Pinprick + Light touch)
—> 0: Absent
—> 1: Different compared with face
—> 2: Normal
—> Total sensory index score: 112 (56 per side) - Dexterity (Fine motor functions of hands)
- Coordination
- ***Proprioception (Romberg’s test)
- ***Gait
- ***Sphincter
Special tests:
1. Alignment
2. **Lhermitte sign
- flexion of neck —> cervical instability (e.g. C1/2 subluxation) —> **cord compression —> sharp radiating symptoms down all 4 limbs
3. **Spurling test (~ Straight leg raise test in Lumbar spine)
- lateral flexion + extend + axial compression on head to narrow foramen —> **radicular pain
4. **Cervical myelopathy signs
- Upper limb: **Myelopathic hand signs
- Lower limb: Spasticity, Clonus, Brisk jerks, Babinski upgoing, Romberg’s test, Gait
Significance:
- Examination provides symptomatic disc level
- Spinal cord ascends during development —> disc lie opposite to cord segment **one lower than root passing them (i.e. L4/5 disc herniation —> compress on L5 nerve root + **L6 cord)
Dermatomes and Myotomes
Dermatomes:
- C4: Shoulder
- C5: Lateral elbow
- C6: Thumb
- C7: Middle finger
- C8: Little finger
- T1: Medial elbow / axilla
Myotomes:
***C3-5: Diaphragm
C5: Elbow flexors (Biceps)
C6: Wrist extensors (Extensor carpi radialis)
C7: Elbow extensors (Triceps)
C8: Finger flexors (Long flexors of digits)
T1: Intrinsic hand muscles (Finger adductors)
L2: Hip flexors (Iliopsoas)
L3: Knee extensors (Quadriceps)
L4: Ankle dorsiflexors (Tibialis anterior)
L5: Long toe extensors (Extensor hallucis longus)
S1: Ankle plantar flexors (Gastrocsoleus)
S2: Anal sphincter
Investigations of Neck
- Blood tests
- X-ray
- Oblique views (for ***Neuroforamen) - Myelograthy (rare now)
- CT (fracture)
- MRI
- cord compression
- disc herniation
- structural pathologies
***Interpret X-ray of Neck
- Alignment
- ***Pre-vertebral / Retropharyngeal soft tissue shadow
—> at C2 level: soft tissue thickness anterior vertebra should be <1/2 width of vertebral body (2-3mm)
—> at C4 level: soft tissue starts widening (3-4mm) (∵ epiglottis + esophagus)
—> at C7 level: < entire width of vertebral body
—> children: “apparent” thicker soft tissue due to cartilaginous bone making vertebral body smaller
- Anterior longitudinal line
- Posterior longitudinal line
- Spinal laminar line
- Spinous process (AP (rotation / malalignment) + Lateral view)
- Normal cervical lordosis - Bone
- Size + Height
- Vertebral body (~ size in all cervical vertebrae)
- Lateral mass (facet joint in-between)
- Spinous process
- Uncovertebral joints - Collapse
- Disc space
- Smooth
- Similar size in all cervical levels - End plates
- Smooth -
**Flexion instability
- **Anterior Atlantodental interval (AADI): distance between posterior aspect of anterior C1 arch and anterior border of C2 dens —> should be **same in flexion + extension (~4mm)
- **Posterior Atlantodental interval (PADI): distance between anterior aspect of posterior C1 arch and posterior border of C2 dens (>11mm) - Risk factors
- Developmental stenosis: Pavlov ratio (spinal canal diameter: vertebral body ratio —> usually 1:1)
- Dynamic stenosis (flexion vs extension): distance between Inferior posterior angle of vertebral body to Superior anterior portion of spinous process at ***a level below (>11mm)
- Disk herniation
- Cervical less common vs Lumbar (∵ less stress)
- Repetitive strain —> nucleus pulposus loses competence —> annular tear —> radial fissures —> nucleus pulposus herniation ***“Soft disk” (Degeneration —> Prolapse —> Extrusion —> Sequestration)
2 mechanisms of radiculopathy:
1. Inflammation of nerve root
- proteoglycans / phospholipase from nucleus pulposus initiates inflammatory cascade
2. Direct compression of nerve root
3 types of compression:
1. ***Intraforaminal
- Motor + Sensory deficit
(- Horner’s syndrome (if compress on sympathetic ganglion))
- ***Posterolateral
- Motor-predominant deficit (∵ compress mainly on ventral roots) -
**Midline
- **Myelopathy
- Cervical spondylosis
Degeneration of cervical spine (NOT indicate nerve compression)
- Degenerative disk —> Disk collapse —> Uncovertebral joints come into contact + facet joints overload —> osteophytes ***“Hard disk” —> nerve compression
Contact points between cervical spine:
- 2 facet joints
- 2 uncovertebral joints
- IV disc
Facet arthrosis (facet arthropathy):
- Articular cartilage degeneration
- Inflammation
- Synovitis
- Capsular contracture
- Uneven load bearing
- Osteophyte formation
—> ALL can lead to pain
Treatment:
1. Conservative
- Physiotherapy
- Traction
- Muscle strengthening
- Analgesic
- Surgery
- No evidence for cervical spondylosis
- Indications: **Neurology, **Instability, ***Deformity
Radiculopathy vs Myelopathy (+ SpC Revision)
Radiculopathy:
- Root compression (LMN)
- Dermatomal (Radiating pain)
- Numbness + Weakness
- Hyporeflexia
- Spurling’s test +ve
- Wax + wane
- Self-limiting (80%), Progression uncommon
- Sensory only
Myelopathy:
- Cord compression (UMN)
- Numbness + Clumsiness + Spasticity
- Hyperreflexia: Clonus / Upgoing Babinski
- Hand signs +ve: 10 second test, Hoffman, Finger escape
- Lower limb involvement
- Downhill course, Slow stepwise worsening
- 3 types of progression: Episodic progression (75%), Steady progression (20%), Rapid deterioration (5%)
- Cervical radiculopathy
- Root irritation
- Compatible spinal level
Clinical features:
- Sharp pain and tingling / burning sensations (Dermatomal)
Causes:
1. **Disc degeneration / herniation
2. **Osteophytes (at uncovertebral joint / facet)
DDx:
1. **Peripheral entrapment syndromes
2. **Rotator cuff / shoulder pathology
3. ***Brachial plexus neuritis
4. Herpes zoster
5. Sympathetic mediated pain syndrome
6. Intraspinal / Extraspinal tumour
7. Epidural abscess
8. Cardiac ischaemia
Investigations:
1. X-ray C-spine (for ***Spondylosis features)
- AP / Lateral: Disc space narrowing, Osteophyte
- Oblique: Foraminal stenosis
- Electrophysiological studies
- NCV, Needle EMG
- “Extension of physical examination”: useful if equivocal P/E findings (e.g. complex neurologic deficit patterns e.g. mixture of DM neuropathy + cervical radiculopathy)
Treatment:
1. Conservative
- Medication / Injection
- Neck exercise
- Physiotherapy
- Avoidance of poor posture to prevent occurrence
- Surgery
- Persistent symptoms despite conservative treatment that are compatible with imaging (i.e. make sure not other causes leading to radiculopathy e.g. DM neuropathy)
- Motor deficit
—> Facet joint, Osteophyte: Posterior approach
—> Disc: Anterior approach
- Cervical myelopathy
- ***Grey matter (cell bodies) more susceptible —> not recover
- Deterioration
—> 70% do
—> Stepwise / Slow / Rapid
Causes:
1. ***Spondylotic myelopathy
- Anterior: Disc herniation, OPLL (ossification of posterior longitudinal ligament)
- Posterior: Ligamentum flavum hypertrophy
- Lateral: Facet joints hypertrophy
- ***Cervical instability (e.g. C1/2 instability)
- Posterior arch impinge in spinal canal - Spinal tumour (SpC Revision)
DDx:
- ***Peripheral neuropathy
Clinical features:
1. Non-specific symptoms
2. Generalised fatigue
3. **Numbness in upper + lower limbs
4. Weakness
5. **Clumsiness of hands (loss of fine motor)
6. **Loss of balance (Wide-based gait)
7. **Gait disturbance (Stiff knee / Spastic gait / Wide-based gait)
8. Bladder and bowel impairment
9. Neck pain (usually **none except in **Cervical spondylotic myelopathy: pain due to degeneration of disc / facet joint)
Investigations:
1. X-ray
- look for risk factors
—> Developmental stenosis: Pavlov ratio (spinal canal diameter: vertebral body ratio —> usually 1:1)
—> Dynamic stenosis (flexion vs extension): distance between Inferior posterior angle of vertebral body to Superior anterior portion of spinous process at ***a level below (>11mm)
- MRI
- T2 myelomalacic changes: “Snake eyes” —> cystic necrosis + early proton changes (white signals) in grey matter —> ***cell body undergo degeneration
- T1 hypointensity (black spots in spinal cord)
—> poor prognosis for myelopathy recovery
Treatment:
1. Surgery
- Laminoplasty (increase size of space from anterior aspect of spinous process to posterior vertebral body)
- **Anterior spinal decompression + fusion
(2. Prophylactic decompression for stenotic patients?)
(*NO conservative treatment ∵ myelopathy will always deteriorate)
Outcome measures:
1. ***Modified Japanese Orthopaedic Association Score (mJOA)
- Motor dysfunction of UL, LL
- Sensation
- Sphincter problem
- Total of 17
- JOACMEQ
- Patient perceived outcomes
***Cervical myelopathy signs
- UMN signs
- Spasticity
- Brisk jerks
- **Inverted supinator reflex (C5/6 lesion)
- Scapulohumeral reflex (C3 cord compression) (tap on acromion / supraspinatus tendon —> shoulder elevation / upgoing deltoid shrug (abnormal))
- **Babinski upgoing
- **Clonus (Ankle / Knee) (abnormal reflex arch)
- Myelopathic hand signs - Balance
- ***Romberg’s sign
- Stiff knee / Spastic gait / Wide-based gait
**Myelopathic hand signs
1. Hoffman’s sign
- wrist resting on surface + extended, one hand hold sides of middle finger MCPJ, other hand flick distal phalanx
- involuntary finger flexion (monosynaptic stretch reflex)
- disinhibition of **C8 reflex
- normal people may have
-
**10 Seconds test
- grip and release test: **>20 within 10 seconds
- **dyskinesia (cannot open all fingers at the same time)
- way of open / close hand more important than number of times within 10 seconds
- **most useful test indicating clumsiness in cervical myelopathy - Inverted supinator reflex (***C5/6 lesion)
- loss of normal supinator reflex + flexion of other fingers - Finger escape sign (indicate intrinsic weakness, ***ulnar nerve palsy may mimic but usually unilateral)
- grade 0-4
—> grade 0: all finger normal
—> grade 1: little finger unable to hold adduction
—> grade 2: little + ring finger unable to assume adduction
—> grade 3: little + ring finger unable to assume adduction / full extension
—> grade 4: little + ring + middle finger unable to assume adduction / full extension
